Download CQC Matrix UPDATED March 2016

CQC STANDARDS MATRIX FOR MEDICINES MANAGEMENT INFORMATION
This document provides examples of those resources that you may wish to use as part of your evidence when looking at compliance with CQC medicines requirements.
Throughout the document, blue underlined text indicates a hyperlink – hold the CTRL key and click the link to visit the resource that has been referenced. In some cases,
the resources have been inserted into the document as an object – if you see a symbol representing Microsoft Word or Adobe PDF, you can double click the symbol to
open the resource.
CQC 9A – Providing personalised care through the effective use of medicines
Standard/Outcome
Policies
Resources
Audits / tools
Comments
Repeat Dispensing audit
Ensures the medicines given are
appropriate and person-centred by
taking account of their:

Age, choices, lifestyle

cultural and religious beliefs

allergies and intolerances

existing medical conditions and
prescriptions

adverse drug reactions

recommended prescribing regimes
Repeat Disp
Audit.doc
Medicines Code Chapter 5:
Adverse Drug Reactions
Medicines Code Chapter 2:
Prescribing policy
Medicines code Chapter 15:
Repeat prescribing and
medicines review policy
Medicines Reconciliation
audit
Pan-Dorset Prescribing
Formulary
BNF online
Audit - Medicines
Reconcilation.xls
Repeat prescribing risk
assessment tool
REPEAT RISK
TOOL.doc
1
Practice
procedures/protocols for
prescribing will also be
relevant to this standard
Standard/Outcome
Policies
Resources
Audits / tools
Comments
Medicines Review audit
(patients >65 on ≥10 meds)
Ensures the person’s prescription for
medicines, for which the service is
responsible, is up to date and is
reviewed and changed as their needs or
condition changes.
Medicines code Chapter 15:
Repeat prescribing and
medicines review policy
Template policy for
medicines reconciliation
Template Policy.docx
Audit - Med Review
10 meds.xls
Inhaled corticosteroid audit
(patients on very high doses)
Practice procedures /
protocols for medicines
review and medicines
reconciliation will be relevant
to this standard
Audit - High Dose
ICS in Asthma.xls
Includes monitoring the effect of their
medicines and action when necessary if
their condition changes, including side
effects and adverse reactions.
Includes supporting and reminding
them to self-administer their medicines
independently where they are able and
wish to do so by minimising the risk of
incorrect administration.
Medicines code Chapter 15:
Repeat prescribing and
medicines review policy
Template policy for
medicines reconciliation
Template Policy.docx
Medicines Review audit
(patients >65 on ≥10 meds)
Audit - Med Review
10 meds.xls
Insulin passport
2013 RCN guidance on
Administering subcutaneous
methotrexate for
inflammatory arthritis
includes:
Oral anticoagulant book

Training checklist for
HCPs to train a
patient/carer to selfadminister subcutaneous
methotrexate

Specialist practitioner
competency checklist
Methotrexate alert book
Lithium alert card
2
Practice procedures /
protocols for medicines
review and medicines
reconciliation will be relevant
to this standard
Practice procedures /
protocols for training patients
to self-administer medication
(e.g. methotrexate or insulin)
will be relevant to this
standard
Standard/Outcome
Policies
Resources
Audits / tools
‘Keep Taking the Tablets’
newsletter contains details of
how to contact Medicines
Information Centre at
Southampton
Follows clear procedures in practice,
which are monitored and reviewed,
which explain how up-to-date
medicines information and clinical
reference sources for staff are made
available.
Comments
Consider any in-house
training offered to staff and
any medicines related
reference sources available
within the practice
BNF online
Use of the dedicated CCG
medicine.question@dorsetcc
g.nhs.uk address for medicine
/ prescription related queries
CQC 9B – Manage risk through effective procedures about medicines handling
Standard/Outcome
Policies
Clear procedures followed in practice,
monitored and reviewed for medicines
handling that include obtaining, safe
storage, prescribing, dispensing,
preparation, administration, monitoring
and disposal.
Medicines Code Policies (e.g.
prescribing policy, waste
medicines policy).
Clear procedures, that are followed in
practice, monitored and reviewed, for
controlled drugs, unless they are taken
by the person themselves in their own
home
Medicines code chapter 7:
Development and
Implementation of SOPs
Medicines Code Chapter 19:
Destruction of Controlled
Drugs
Medicines Code Chapter 20:
Prescribing and Management
of Controlled Drugs
Resources
Audits / tools
Prescribing data, visits from
the Prescribing Advisors, and
associated action plans also
provide evidence that
prescribing data is subject to
peer review.
Pan-Dorset Prescribing
Formulary (includes shared
care guidance)
Department of Health
guidance on standards for CD
SOPs
CDs - DOH guidance
on SOPs.pdf
3
Comments
CQC self assessment tool for
CDs in primary care
Practice should have local
SOPs for specific processes
undertaken relating to
controlled drugs
Standard/Outcome
Systems in place to reflect on the
findings of their service reviews and as
it does so, learns from adverse events,
incidents, errors and near misses
relating to medicines that have
occurred within the service and
elsewhere, so that the risk of them
being repeated is reduced to a
minimum
Systems in place to ensure they comply
with the requirements of the Medicines
Act 1968 and the Misuse of Drugs Act
1971, and their associated regulations,
the Safer Management of Controlled
Drugs Regulations 2006, relevant health
technical memoranda and professional
guidance from the Royal
Pharmaceutical Society of Great Britain
and other relevant professional bodies
and agencies
Policies
Dorset CCG Adverse incident
reporting policy
Medicines Code Chapter 5:
Adverse Drug Reactions
Resources
Audits / tools
Practice may also have local
significant event processes
for review and learning, e.g.
practice meetings.
Instructions and guidance for
reporting a patient safety
incident to the National
Reporting and Learning
Service
Prescribing data and visits
from Prescribing Advisers also
provide evidence that
prescribing data is subject to
peer review.
Reporting adverse reactions
via the Yellow Card System
Medicines Code Chapter 20:
Prescribing and Management
of Controlled Drugs
(incorporating destruction of
controlled drugs)
Guidance on controlled drug
prescribing in substance
misuse
Checklist for dispensing
practices for assessing
adherence to legal and best
practice requirements
relating to controlled drugs
CD Best practice
guidance (GP) CCG Aug 2013.pdf
CD checklist
(dispensing practices).doc
Guidance for managing
difficult patients
Checklist for resolving a
discrepancy between
controlled record book and
actual stock level
Difficult to manage
patients (Sept 2013).pdf
Checklist for CD
Register Discrepancy.pdf
4
Comments
Consider any in-house
training offered to staff
CQC 9C
People who use services benefit from a service that takes into account relevant guidance set out in the Care Quality Commission’s Schedule of Applicable Publications.
Standard/Outcome
Policies
Resources
Takes into account relevant guidance set out in the
Care Quality Commission’s Schedule of Applicable
Publications
Medicines Code Policies
*Applicable Publications,
see below this table
Audits / tools
Comments
*Applicable Publications:
Relevant evidence-based guidance and alerts about medicines management and good practice published by appropriate expert and professional bodies, including:







National Patient Safety Agency (NPSA)
National Institute for Health and Clinical Excellence (NICE)
Medicines and Healthcare products Regulatory Agency (MHRA)
Department of Health (DH)
Royal Pharmaceutical Society of Great Britain (RPSGB)
Social Care Institute for Excellence (SCIE)
Medical and other clinical royal colleges, faculties and professional associations (e.g. GMC, BMA, NMC, RCN).
Specific documents:



The safe and secure handling of medicines: a team approach (RPSGB, 2005)
The handling of medicines in social care (RPSGB, 2007)
Research governance framework for health and social care: Second edition (DH, 2005)
5
CQC 9D – People who use services benefit from a service that:
Standard/Outcome
Ensures that wherever possible, information is
available for people about the medicines they are
taking, including the risks.
Policies
Resources
Audits / tools
Comments
For dispensing practices –
provision of patient
information leaflets with
dispensed medicines
Medicines Code Policies
Patient leaflets:
Ensures information is available for people about
medicines advisable for them to take for their health
and wellbeing and also to prevent ill health.
Ensures there is access for staff to up-to-date
legislation and guidance related to medicines
handling.
Ensures best interest meetings are held with people
who know and understand the person using the
services when covert administration of medicines is
being considered, to decide whether this is in the
person’s best interest.

28 day prescribing

Generic prescribing

Changes to medicines

Safety with fentanyl
patches
Use of resources such as
‘Keep Taking the Tablets’
newsletter and useful
resources on the
formulary section of the
CCG website
UKMi Q&A: What legal
and pharmaceutical issues
should be considered
when administering
medicines covertly?
UKMi covert
admin.pdf
6
Provision of leaflets and
visual information on
healthcare in the surgery
Referrals/signposting, e.g.
SmokeStop
Yearly DSQS submission
for dispensing practices
Practice policy on covert
administration (if this is
necessary for care home
patients)
CQC 9F – People who use services receive care, treatment and support that:
Standard/Outcome
Policies
Resources
Audits / tools
Template guidance for
care homes on homely
remedies (practices may
share and agree with care
homes)
Follows clear procedures in practice, which are
monitored and reviewed and that explain how care
home staff may be permitted to administer homely
remedies.
Comments
Practice policies in place
in care homes for whom
the practice prescribes
will be relevant to this
standard
12 - Homely
remedies.doc
CQC 9G – Where people who use services receive support with their medicines, the provider has:
Standard/Outcome
Additional clear procedures followed in practice,
monitored and reviewed for medicines handling that
include obtaining, administration, monitoring and
disposal. Wherever they are required these
procedures include:


how clinical trials are carried out in line with
relevant laws, current guidelines and ethics
committee approval
Policies
Resources
Knowing how to share
controlled drugs with the
CD Accountable Officer
Medicines Code Policies
CDs - New
Accountable Officer.pdf
sharing concerns about medicines handling.
Established arrangements for obtaining
pharmaceutical information by a person who
understands the care, treatment or support that is
provided by the service.
Use of the dedicated CCG
medicine.question@dorse
tccg.nhs.uk address for
medicine / prescription
related queries
7
Audits / tools
Comments
For dispensing practices:
dispensary SOPs and
standards will be relevant
to this standard
CQC 9H – People who use services receive care, treatment and support that:
Standard/Outcome
Policies
Resources
Audits / tools
UK Resuscitation Council:
Emergency treatment
Ensures medicines required for resuscitation or other
medical emergencies are accessible in tamper
evident packaging that allows them to be
administered as quickly as possible.
Comments
This is included as part of
the QOF framework
of anaphylactic reactions
Guidelines for healthcare
providers
CQC 9J – Ensure that patient safety alerts, rapid response reports and patient safety recommendations disseminated by the National Patient Safety Agency and which
require action are acted upon within required timescales.
Title
Issue date
Policies
Resources
Audits / tools
Booklet for healthcare
professionals
Valproate and risk of abnormal
pregnancy outcomes
February
2016
MHRA Safety Alert (via
Central Alerting System)
Consultation checklist
Guide to give to patients
Card to give to patients
Medicines optimisation: the safe and
effective use of medicines to enable the
best outcomes
Mar 2015
Risk of death from asphyxiation by
accidental ingestion of fluid/food
thickening powder
February
2015
Prevention of Harm with Buccal
Midazolam
Feb 2012
Medicines code chapter
14: Medicines
Reconciliation
Medicines Reconciliation
audit
NICE guidance
Audit - Medicines
Reconcilation.xls
NHS England Safety Alert
(via Central Alerting
System)
NPSA information
MHRA information
8
Comments
Title
Issue date
Policies
Resources
Prevention of harm with alfacalcidol
preparations
Sept 2011
The adult patient’s passport to safer use
of insulin
Mar 2011
Preventing fatalities from medication
loading doses
Nov 2010
NPSA information
Reducing treatment dose errors with
LMWH
Jul 2010
NPSA information
Safer administration of insulin
Jun 2010
Medicines code chapter
11: Prescribing insulin
NPSA information
Reducing harm from omitted and
delayed medicines in hospital
Feb 2010
Medicines code chapter
14: Medicines
Reconciliation
NPSA information
Audits / tools
Comments
NPSA information
Medicines code chapter
11: Prescribing insulin
NPSA resources
NPSA Rapid Response
Report
Vaccine cold storage
Jan 2010
Medicines code chapter
16: Temperature
monitoring of medicinal
products
Safer lithium therapy
Dec 2009
Medicines code chapter
10: Prescribing lithium
Inadvertent use of female urinary
catheters in adult males
Apr 2009
NPSA Rapid Response
Report
Reducing risk of harm from oral bowel
cleansing solutions
Feb 2009
NPSA Rapid Response
Report
Reducing risk of overdose with
midazolam injection in adults
Dec 2008
NPSA Rapid Response
Report
Department of Health
Protocol for ordering,
storing and handling
vaccines
NPSA Patient Safety Alert
9
Practice procedure for
checking fridge
temperatures and actions
to be taken to remedy
out-of-range
temperatures
Title
Issue date
Reducing dosing errors with opioid
medicines
July 2008
Oral anti-cancer medicines: risks of
incorrect dosing
Jan 2008
Fire hazard with paraffin-based skin
products
Nov 2007
Policies
Resources
Audits / tools
Comments
NPSA Rapid Response
Report
NPSA Rapid Response
Report
Newsletter bulletin
Promoting safer use of injectable
medicines
Mar 2007
Medicines code chapter
21: Injectable medicines
NPSA Patient Safety Alert
NPSA alerts (March
2008).doc
Newsletter bulletin
Promoting safer measurement and
administration of liquid medicines via
oral and enteral syringes
Mar 2007
NPSA Patient Safety Alert
NPSA alerts (March
2008).doc
Anticoagulant Audit
Actions that can make anticoagulant
therapy safer
Mar 2007
Improving compliance with oral
methotrexate guidelines
Jun 2006
High dose morphine and diamorphine
injections
May 2006
Medicines code chapter
13: Oral anticoagulant
prescribing
NPSA Patient Safety Alert
Medicines code chapter 9:
Prescribing Methotrexate
NPSA Patient Safety Alert
NPSA Anticoag
Audit.doc
NPSA Safer Practice
Notice
10
Newsletter bulletin
NPSA alerts (March
2008).doc
Important alerts / national priorities
Title
Policies
NICE guidance on managing
medicines in care homes
Resources
Audits / tools
NICE guidance
NICE baseline assessment tool
CHUMS study
Care Homes Use of Medicines
(CHUMS) Report
Report on CHUMS in the BMJ
Template policy for medicines
reconciliation
Managing Patient’s Medicines on
Discharge (MPMD) Report
Medicines Reconciliation
audit
Medicines code chapter 14:
Medicines Reconciliation
Template Policy.docx
Report on the prescribing of antipsychotic drugs to people with
dementia (Banerjee)
Comments
Audit - Medicines
Reconcilation.xls
Antipsychotics in Dementia
Audit
Banerjee report.pdf
Audit Antipsychotics in Dementia.doc
Repeat (Batch) Dispensing
audit
Reduction of waste medicines
Repeat Disp
Audit.doc
Participation in waste
campaigns in recent years
Any practice initiatives to
encourage patients to only
order what they need
This list is not comprehensive as new alerts and national priorities are issued regularly, but provides a guide for the major publications of the last few years.
11
2016 ‘Never Events’ relevant to medicines in primary care (refer to NHS England website for full list)
Title
Policies
Resources
Audits / tools
Overdose of insulin due to
abbreviations or incorrect device
Medicines code chapter 11:
Prescribing insulin
NPSA information
Overdose of methotrexate for noncancer treatment
Medicines code chapter 9:
Prescribing Methotrexate
Additional notes
12
Comments